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The difficulty of comparing drug prices between countries
Correspondence
The difficulty of comparing drug prices between countries In the Comment on actual cost of cancer drugs in 15 European countries by Wim van Harten and colleagues, 1 the authors present a list of formal and actual prices of nine expensive cancer drugs. The prices were provided by the members of the European Organization of Cancer Institutes and Cancer Core Group. Without questioning the interest and the value of the Comment, we wish to stress that both the formal and actual prices mentioned for Belgium are not correct. Indeed, both prices shown in the table in the Comment are higher than the actual and official ones used in Belgium. The maximum prices authorised by the Belgian authorities (Ministry of Economic Affairs) are presented here and are compared with the prices mentioned in van Harten and colleagues’ Comment. The actual price can be lower than the formal price when a managed entry agreement has been concluded between the company and the authorities. In addition, potential rebates can be negotiated by hospitals and pharmacists. This situation only stresses how difficult it is to make price comparisons between countries because the information about drugs price and cost is indeed difficult to obtain, remains highly sensitive, and is often confidential. Initiatives like the structural cooperation around orphan drugs (horizon scanning, gathering and assessment of scientific evidence, joint negotiations, and common registries) that I have initiated with my colleagues from the Netherlands and Luxemburg should allow policy makers and authorities alike to partly overcome this problem. I declare no competing interests.
www.thelancet.com/oncology Vol 17 April 2016
Maximum authorised price (€)
Formal price listed in the Comment (€)
Price difference (€)
Trastuzumab 150 mg/1 vial
517·83
536·76
Rituximab 100 mg/1 vial
210·45
218·38
–18·93 –7·93
Imatinib 100 mg/tablet
19·37
20·31
–0·94
Sunitinib 12·5 mg/tablet
43·38
46·45
–3·07
Vemurafenib 240 mg/tablet
30·20
34·82
–4·62 –85·92
Drugs under managed entry agreement Pertuzumab 420 mg/1 vial
2754·74
2840·66
Bevacizumab 100 mg/1 vial
308·08
322·89
Ipilimumab 50 mg/1 vial Enzalutamide 40 mg/1 vial
4250 26·13
–14·81
4380·80
–130·8
28·35
–2·2
Table: Comparison between Belgium’s maximum authorised drug prices and formal drug prices given by van Harten et al1
Maggie De Block [email protected] Ministery of Public Health and Social Affairs, 1000 Brussels, Belgium 1
van Harten WH, Wind A, de Paoli P, Saghatchian M, Oberst S. Actual costs of cancer drugs in 15 European countries. Lancet Oncol 2016; 17: 18–20.
Carfilozomib versus bortezomib for relapsed or refractory myeloma Meletios Dimopoulos and colleagues1 are to be congratulated for their milestone study comparing carfilozomib with bortezomib, each with dexamethasone, for relapsed or refractory myeloma. I am puzzled that the median duration of treatment for patients receiving carfilzomib was 39·9 (IQR 23·7–53·0) weeks (9·2 months), whereas the median progressionfree survival for this group was 18·7 (95% CI 15·6 to not estimable) months. Since neuropathy was rare in the carfilzomib group, it remains unclear why treatment was apparently stopped for a large proportion of patients when their myelomas were still responding and in the absence of severe toxic effects. Only 50 (11%) of 464 patients in the carfilzomib group achieved complete response, so it is unlikely that many patients stopped chemotherapy
early because they or their physicians thought that the goals of treatment had been achieved is unlikely. Since moderate or severe sensory neuropathy was common in the bortezomib group, one would expect that cessation of treatment when disease was still controlled would be common in that group. In table 3 of the study, Mild or moderate neuropathy was reported only in 8% of patients in the carfilzomib group. 46% of patients treated with carfilzomib had residual neuropathy from earlier therapy at study entry. Only 10 (2%) of 456 patients taking carfilzomib developed severe neuropathy. Neuropathy was an unlikely cause for early cessation of effective carfilzomib therapy. Of the 263 patients who stopped treatment of carfilzomib with dexamethasone, 65 (25%) did so because of adverse events (table 5 of the appendix). We should be told the nature of these adverse events, but unfortunately, table 6 of the appendix does not make them clear. Since prolongation of progressionfree survival was the primary endpoint of the study, the issue of whether patients were actually treated to time of progression or until severe toxic effects appeared is very important. If a large proportion of patients taking carfilzomib actually stopped effective treatment early in the absence of severe toxic effects, then carfilzomib might be even e125
The difficulty of comparing drug prices between countries In the Comment on actual cost of cancer drugs in 15 European countries by Wim van Harten and colleagues, 1 the authors present a list of formal and actual prices of nine expensive cancer drugs. The prices were provided by the members of the European Organization of Cancer Institutes and Cancer Core Group. Without questioning the interest and the value of the Comment, we wish to stress that both the formal and actual prices mentioned for Belgium are not correct. Indeed, both prices shown in the table in the Comment are higher than the actual and official ones used in Belgium. The maximum prices authorised by the Belgian authorities (Ministry of Economic Affairs) are presented here and are compared with the prices mentioned in van Harten and colleagues’ Comment. The actual price can be lower than the formal price when a managed entry agreement has been concluded between the company and the authorities. In addition, potential rebates can be negotiated by hospitals and pharmacists. This situation only stresses how difficult it is to make price comparisons between countries because the information about drugs price and cost is indeed difficult to obtain, remains highly sensitive, and is often confidential. Initiatives like the structural cooperation around orphan drugs (horizon scanning, gathering and assessment of scientific evidence, joint negotiations, and common registries) that I have initiated with my colleagues from the Netherlands and Luxemburg should allow policy makers and authorities alike to partly overcome this problem. I declare no competing interests.
www.thelancet.com/oncology Vol 17 April 2016
Maximum authorised price (€)
Formal price listed in the Comment (€)
Price difference (€)
Trastuzumab 150 mg/1 vial
517·83
536·76
Rituximab 100 mg/1 vial
210·45
218·38
–18·93 –7·93
Imatinib 100 mg/tablet
19·37
20·31
–0·94
Sunitinib 12·5 mg/tablet
43·38
46·45
–3·07
Vemurafenib 240 mg/tablet
30·20
34·82
–4·62 –85·92
Drugs under managed entry agreement Pertuzumab 420 mg/1 vial
2754·74
2840·66
Bevacizumab 100 mg/1 vial
308·08
322·89
Ipilimumab 50 mg/1 vial Enzalutamide 40 mg/1 vial
4250 26·13
–14·81
4380·80
–130·8
28·35
–2·2
Table: Comparison between Belgium’s maximum authorised drug prices and formal drug prices given by van Harten et al1
Maggie De Block [email protected] Ministery of Public Health and Social Affairs, 1000 Brussels, Belgium 1
van Harten WH, Wind A, de Paoli P, Saghatchian M, Oberst S. Actual costs of cancer drugs in 15 European countries. Lancet Oncol 2016; 17: 18–20.
Carfilozomib versus bortezomib for relapsed or refractory myeloma Meletios Dimopoulos and colleagues1 are to be congratulated for their milestone study comparing carfilozomib with bortezomib, each with dexamethasone, for relapsed or refractory myeloma. I am puzzled that the median duration of treatment for patients receiving carfilzomib was 39·9 (IQR 23·7–53·0) weeks (9·2 months), whereas the median progressionfree survival for this group was 18·7 (95% CI 15·6 to not estimable) months. Since neuropathy was rare in the carfilzomib group, it remains unclear why treatment was apparently stopped for a large proportion of patients when their myelomas were still responding and in the absence of severe toxic effects. Only 50 (11%) of 464 patients in the carfilzomib group achieved complete response, so it is unlikely that many patients stopped chemotherapy
early because they or their physicians thought that the goals of treatment had been achieved is unlikely. Since moderate or severe sensory neuropathy was common in the bortezomib group, one would expect that cessation of treatment when disease was still controlled would be common in that group. In table 3 of the study, Mild or moderate neuropathy was reported only in 8% of patients in the carfilzomib group. 46% of patients treated with carfilzomib had residual neuropathy from earlier therapy at study entry. Only 10 (2%) of 456 patients taking carfilzomib developed severe neuropathy. Neuropathy was an unlikely cause for early cessation of effective carfilzomib therapy. Of the 263 patients who stopped treatment of carfilzomib with dexamethasone, 65 (25%) did so because of adverse events (table 5 of the appendix). We should be told the nature of these adverse events, but unfortunately, table 6 of the appendix does not make them clear. Since prolongation of progressionfree survival was the primary endpoint of the study, the issue of whether patients were actually treated to time of progression or until severe toxic effects appeared is very important. If a large proportion of patients taking carfilzomib actually stopped effective treatment early in the absence of severe toxic effects, then carfilzomib might be even e125